Many consumers lose their doctors under new insurance coverage

By Kelli Kennedy

The first thing Michelle Pool did before picking a plan under the federal health care law was check whether her longtime primary-care doctor was covered. But when Pool, a 60-year-old diabetic who has had back surgery and a hip replacement, purchased a plan, she learned the insurer was mistaken.

The $352-a-month gold plan through Covered California’s exchange was cheaper than what she’d paid under her husband’s insurance and seemed like a good deal because of her numerous pre-existing conditions. But after her insurance card came in the mail, Pool, of Vista, Calif., learned her doctor wasn’t taking her new insurance.

"It’s not fun when you’ve had a doctor for years and years that you can confide in and he knows you," Pool said. "I’m extremely discouraged. I’m stuck."

Stories like Pool’s are emerging as more consumers realize they bought plans with limited doctor and hospital networks, some after websites mistakenly said their doctors were included.

Before the law took effect, experts warned that narrow networks could affect patients’ access to care, especially in cheaper plans. But with insurance cards now in hand, consumers are finding limited access across all price ranges.



The trade-off on costs

Narrow networks are part of the economic trade-off for keeping premiums under control and preventing insurers from turning away those with pre-existing conditions. Even before the Affordable Care Act, doctors and hospitals would choose to leave a network — or be pushed out — over reimbursement issues as insurers tried to contain costs.

The insurance trade group America’s Health Insurance Plans said studies show the biggest factor influencing consumer choice is price. Insurers say that if consumers want low premiums, their choices may be limited.

Insurance companies also argue that there’s wide variation in what doctors and hospitals charge, with some increasing prices every year. Insurers say there’s little evidence that higher-priced hospitals or doctors are actually delivering better care.

Further complicating matters, the trade group said, is that doctors and health plans often renegotiate throughout the year, meaning a doctor listed in a network at the time of enrollment may not be there a few months later.

Insurance agents Craig Gussin in San Diego and Kelly Fristoe in Texas helped dozens of clients switch plans just before the enrollment deadline, after clients realized their doctors weren’t covered. Now they’re struggling to help clients who realized they were in that position after the March 31 deadline, when consumers were locked into plans for one year.

Gussin said that even after his mad dash to make switches before the deadline, he still has a half-dozen clients who are stuck — and he expected the number to grow.

He and other agents said they fear it will be one of their most serious issues in 2014.

"Everybody I talk to is having the same issue. It’s probably the No. 1 item that we’re seeing right now," said Gussin, who is petitioning Covered California for special enrollment status to help clients change plans.



Low-cost upgrades

Health counselor Nathalie Milias, who helped enroll nearly 300 Miami-area residents in plans under the Affordable Care Act, said most people chose a plan with $0 monthly premiums and deductibles — but with much more limited choices. She said tax credits could have allowed them to purchase more robust coverage if they were willing to spend more, but many are working poor people who didn’t want to pay another bill.

Marie Bien-Aime, a 59-year-old cook at a Miami restaurant, enrolled in that plan to avoid a monthly payment, but she realized her longtime health clinic didn’t take the plan. Shortly before the enrollment deadline, Bien-Aime, who was previously uninsured upgraded to a plan that costs $37 per month.

Many consumers are still learning. They hear "Obamacare" and think it’s free, like Medicaid or Medicare, said John Foley, an attorney and health care navigator. "They don’t expect to pay anything," said Foley. "For a couple more dollars a month, you can get a really good plan."

But even with pricier plans, some consumers have access problems.

James Potts’ $647-per-month silver plan was issued by the same company that had insured him with a different plan canceled under the ACA. The 64-year-old property insurance agent assumed his doctors would remain the same under the new plan but didn’t check.

When Potts got a nasty cold, he called three facilities near his home in Wichita Falls, Texas, and was shocked to find that none took the insurance, including his primary-care doctor.

Source Associated Press